Health Train Express

HEALTH TRAIN EXPRESS
Follow or subscribe to Health Train Express as well as Digital Health Space for all the updates for health policy, reform, public health issues. Health Train Express is published several times a week.Subscribe and receive an email alert each time it is published. Health Train Express has been published since 2006.

Tuesday, February 20, 2018

The life expectancy of Native Americans in some states is 20 years shorter than the national average.

There are many reasons why.

Among them, health programs for American Indians are chronically underfunded by Congress. And, about a quarter of Native Americans reported experiencing discrimination when going to a doctor or health clinic, according to findings of a poll by NPR, the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health.

Margaret Moss, a member of the Hidatsa tribe, has worked as a nurse for the Indian Health Service and in other systems. She now teaches nursing at the University of Buffalo.

She says she has seen racism toward Native Americans in health care facilities where she's worked, and as a mom trying to get proper care for her son.

Once, when she was on a health policy fellowship with a U.S. Senate committee, Moss' son had a broken arm improperly set at a non-IHS health facility in Washington, D.C.

She asked the physician about options to correct it, but he told her it was fine, she said. "Even when I, as an educated person using the right words, was saying what needed to happen, [he] didn't want to do anything for us, even though we had a [health insurance] card."

Moss then reluctantly pulled out a business card with the Senate logo, she recalled, and was instantly transformed in the doctor's eyes from "this American Indian woman with my obviously minority son" to someone he could not afford to dismiss.

"It wasn't until the person ... felt they could get in trouble for this ... then the person did something," said Moss. "I felt like it was racism. Not everybody has a card they can just whip out."

She says she feels discrimination is more overt, "in areas where American Indians are known about," like the Dakotas and parts of the American Southwest, but also exists in places without big tribal populations.

In the NPR poll, Native Americans who live in areas where they are in the majority reported experiencing prejudice at rates far higher than in areas where they constituted a minority.

In places where there are few American Indians, Moss says, "people don't expect to see American Indians; they think they are from days gone by, and so you are misidentified. And that's another form of discrimination."

Health care systems outside the Indian Health Service generally see very few Native American patients, because it's so hard for American Indians to access care in the private sector. A lot of that has to do with high poverty and uninsured rates among American Indians, who also often live in rural areas with few health care providers.

"The strikes against people trying to get care are huge: geographic, transportation, monetary," Moss says.

A persistent myth inside and outside Indian Country is that Native Americans get free health care from the federal government.

A persistent myth inside and outside Indian Country is that Native Americans get free health care from the federal government.

Anna Whiting Sorrell, a health care administrator for her tribes, says she is optimistic that the Affordable Care Act will make a big difference for Native Americans. It gives lower-income people access to affordable insurance coverage outside the IHS. Many Natives Americans who weren't eligible for Medicaid before the ACA now are, too.

Moss is more skeptical that the ACA will make a big difference, in part because of entrenched institutional discrimination toward Native Americans in healthcare.

"Until attitudes change," Moss says, "we're still going to be in a sad situation."

Saturday, February 10, 2018

Rapid changes in Health, (digital health) in the U.S. are mirrored around the globe. Canada is making a uniform change and analysis of additions to their health system and adjusting benefits accordingly, using the hard test of time prior to funding.

It’s an exciting time for group benefits in Canada. That’s not a phrase you hear every day, but it’s one that’s coming up more and more often.

Terms like “digital health” and “disruption” are new words to the Canadian benefits vernacular. All of a sudden, it seems like a new digital health startup launches every day and incubators, accelerators and labs are popping up everywhere.

Over the past decade, health plans at all levels in Canada have become much better at managing costs. Employer health plans increasingly requireproof of valuebefore covering a new medical service or pharmaceutical product. The challenge, however, arises when the item under consideration is genuinely new and innovative. As difficult as it is to assess a new prescription drug, evaluating a service unlike anything currently offered can be nearly impossible. By definition, a service that has only existed for two years can’t have demonstrated a long-term return on investment. As a result, good ideas and new technologies face implementation delays.

But what does it all mean for group insurance? What will these new services, startups, innovation labs and disruptors really do to change how plan sponsors and employees manage their health and insurance?

Pharmacogenetics: Personalized medicine is one of the great developments in health care. It has begun to arrive, and pharmacogenetics represent one of the first ways in which we see personalized medicine becoming available to group insurance plans.

Telemedicine: Access to prompt medical advice is one of the most commonly cited shortcomings of the Canadian health-care system. Due to an apparent gap in the definitions under the Canada Health Act, provincial plans generally don’t cover remote or virtual access to physicians. There are now multiple providers of the service on a per-visit or annual subscription basis. For employers, the potential time savings to their employees are significant. Is covering an on-demand video call with a doctor or nurse not more cost-effective than an employee taking time off work to wait at a clinic or in an emergency room?

Pharmacists: The idea of pharmacists doing more than simply dispensing pills by providing value-added services, such as coaching for patients with chronic disease, has been a solution waiting to happen. After years of discussion, the idea has yet to take hold. Why is that? Pharmacists will offer the services if employer benefits plans provide reimbursement. Employer benefits plans, in turn, are open to covering those services once there’s a proven track record of added value.

Gene therapy: The ability to alter someone’s genes to cure a disease (or eliminate the risk of developing one) will soon be a reality. How will benefits plans handle a genetic treatment for a disease, such as cancer, that someone is at risk for but doesn’t yet suffer from?

Health coaching and navigation:Unfortunately, most Canadians don’t get enough time with public health professionals either to stay healthy or get help, when they fall sick, in navigating the system efficiently. As a result, wellness, coaching and navigation alternatives are growing fast, often using technology to personalize and automate the services and thus drive down the cost and improve employee health at the same time.

Virtual care: In-person care has historically been the default way to see a health practitioner. But what if, instead of seeing a psychologist in person for $150 per hour, plan members could treat their mental-health issue by using a cognitive behavioural therapy app on their phone? Is that not worth paying the $60 annual subscription to access it? Despite the potential, most benefits plans haven’t developed a framework to assess the value of or reimburse virtual care.

Health-care spending accounts: New entrants into the group insurance market have sparked a growing debate recently about the role health-care spending accounts could and should play in benefits plans. Given the predictability of many kinds of expenses covered (such as paramedical services, dental recall exams and vision care), the concept of a health-care spending account as the primary source of coverage, with adequate real insurance for catastrophic expenses, is a valid structure to consider.

Medical marijuana: For a variety of reasons, information on both the therapeutic value and cost effectiveness of marijuana in a benefits plan is often still anecdotal. Would a plan that covers medical marijuana see an increase or a decrease in overall costs? For whom and under what circumstances could it be a benefit that outweighs the cost?

When looking at whether to add a new plan feature, employers don’t need to offer it at 100 per cent coverage or to all employees and under all circumstances. Being creative in merging new solutions with established ones will differentiate those plan sponsors that are willing to embrace change and use technology to engage employees in their health.Get creative in making space for new technologies in benefits plans | Benefits Canada

Friday, February 9, 2018

Researchers have developed an algorithm that can identify people previously diagnosed with diabetes in Apple Watch heart data. The learning algorithm provides a strong model for identifying people with diabetes but has yet to prove itself against the tougher task of spotting undiagnosed patients without also racking up false positives.

Cardiogram, an Apple Watch app developer, ran the study (PDF) on 14,011 of its users in conjunction with researchers at UCSF.The data is displayed in the article for several states of heart activity After using data on some of the participants to train a deep neural network, called DeepHeart, the team tested the algorithm on results from the remaining cohort of subjects. The best version of the algorithm recorded a c-statistic of 0.85 in diabetes, making it a strong model.

San Francisco-based Cardiogram is able to identify people with diabetes from heart data because of earlier work that spotted a correlation between variability in cardiovascular activity and the condition.

It was not stated whether the . Apple Watch is HIPAA compliant. HIPAA compliance is a federal regulation which requires all personal identifiying information to be scrubbed from data sources. The article did not expand on this issue.

If Apple files for approval of the app, it will mark a major advance in its long-running flirtation with the healthcare sector. The tech giant stepped up its interest in the space with the introduction of Watch in 2015 and rollout of its ResearchKit framework. Talks with the FDA and involvement in its software precertification pilot program followed. But Apple has yet to seek FDA clearance of a device.

Users of the $199 AliveCor device and accompanying $99-a-year service replace the wristband on their Apple Watch with KardiaBand. Machine learning algorithms, dubbed SmartRhythm, then sift through data gathered by Apple Watch’s sensors to establish a normal band of heart rate activity. If the wearer’s heart rate deviates from these historic norms, the app directs the user to take an EKG.

This is where the band itself comes in. The user places a finger on a sensor built into the strap. The band then performs an EKG, also known as an electrocardiogram, to assess whether the electrical impulses that modulate cardiac contractions are firing properly. The resulting 30-second waveform is shown on the Apple Watch screen, after which the user can share it with their doctor as a PDF.

Aspects of the technology are the same as the credit card-sized device, KardiaMobile, AliveCor already sells for use with smartphones. But the incorporation of the Apple Watch sensors and data into the process stands to change when and why users decide to take an EKG reading.

The big question now is whether this more objective approach to assessing when an EKG is needed will translate into improved outcomes for patients. AliveCor has clinical trial data showing its smartphone-based EKG outperformed routine care. In theory, the Apple Watch-based approach should improve on that product, for the reasons outlined by Topol, but that hypothesis is yet to be tested in the wild.

For the broader digital health sector, the important thing is AliveCor has gained clearance to start finding out how its device performs in the real world at all. AliveCor hustled through the regulatory process far faster in Europe than in the U.S. When AliveCor unveiled the device in March 2016, it talked up the prospect of “late spring” availability. That target came and went as AliveCor grappled with the FDA review process.

Vic Gundotra, the ex-Googler who runs AliveCor, told TechCrunch getting the device to market was “one of the hardest things I’ve ever done in my life.” Under the leadership of Scott Gottlieb, M.D., the FDA may provide an easier route to market for companies that try to follow in AliveCor’s wake. But having put in the hard yards, AliveCor has the field to itself for now.

The FDA process is lengthy and costly for device manufacturers, a barrier for smaller manufacturers. Hopefully this will encourage other ground breaking consumer medical devices to proceed.

Thursday, February 8, 2018

The Embrace device detected every seizure in an epilepsy monitoring unit, and detected most seizures in a real-world setting. (Image: Empatica)

The FDA has approved (PDF) Empatica’s seizure-detecting wearable for use by epilepsy patients. Empatica picked up the 510(k) clearance for Embrace after the device detected every seizure in a 135-patient clinical trial.

Embrace looks like other smartwatches and activity trackers and shares some of their features. The key difference is Embrace pairs its gyroscope, accelerometer and thermometer with an electrodermal activity (EDA) sensor and an algorithm that analyzes the data stream for signs the wearer is suffering a seizure. EDA indicates whether a person is in “fight or flight” mode.

The result is a device and accompanying algorithm that detected every seizure in a 135-patient trial. Empatica demonstrated the accuracy of Embrace by comparing its readout with the opinions of two to three epilepsy experts who had access to video-EEG data but not the results from the wearable. That trial took place in an epilepsy monitoring unit but Empatica has also generated data showing the device detects most seizures when worn by patients in real-world settings.

Embrace detected different types of seizures across the trials, including generalized tonic-clonic seizures. Such seizures cause loss of consciousness and can leave patients confused. This results in the underreporting of the seizures in patient diaries. Embrace’s ability to more accurately detect these events could make it a useful tool for sponsors of epilepsy clinical trials.

The ability of the device to send alerts to caregivers also makes it potentially helpful in the real world. But there is also a risk the device will cause more stress than it alleviates if it triggers false alarms. Empatica has worked to cut the rate of false positives but they still happen. In the 135-person trial, patients experienced one false alarm every two days on average. The rates seen in other studies have been both a little higher and a little lower.

Empatica is betting that is a manageable downside given the potential upsides of the device.

“Tragically, more than 3,000 Americans die each year from sudden unexpected death in epilepsy and the Embrace offers the potential to alarm family members and caretakers that a tonic-clonic seizure is occurring. The scientific evidence strongly supports that prompt attention during or shortly after these convulsive seizures can be life-saving in many cases,” Orrin Devinsky, M.D., director of the Comprehensive Epilepsy Center at NYU, said in a statement.

MIT Media Lab spin-off Empatica is charging $249 for the device and between $9.90 and $44.90 a month for subscriptions that connect to caregivers and provide other features.

Thursday, February 1, 2018

“Are you a left-sider or a right-sider?” my classmate asked with a puzzled look during an end-of-the-year dinner among first-year medical students. I was confused. He repeated himself then answered. “Do you sit on the left or the right side in class … that’s right; you sit on the right.” He then mentioned that everyone present was a “right-sider.” Nearly everyone was white.

For the past 18 months, we sat in a racially arranged way in class: most white people were concentrated on the front to the middle right of the auditorium, black women sat the furthest back, and everybody else sat on the left side with few exceptions. This arrangement translated to the lunch tables and other social settings. We may, at first, think of this divide as different parties sharing equal responsibility, but we live in a society where minorities still have negative experiences in today’s integrated schools. These experiences are linked to a history of structural racism: negative media portrayal, policies perpetuating segregation and impeding upward mobility for racial and ethnic minorities. They experience isolation in different ways, and one of the common coping mechanisms is in-group separation out of self-preservation.

Beverly Tatum expounds on this in her book Why Are All The Black Kids Sitting Together at the Cafeteria Table? She describes different groups’ experiences with race and explains the burden on minorities, especially blacks and Latinos. Self-segregation happens out of self-preservation from macro and micro-aggressions; they need support and cultural understanding from their peers, but also feel less valued and invisible among their white counterparts. This is exacerbated by the landscape in our institutions. The portraits that adorn the walls of our study spaces are almost entirely of white male physicians. I believe the unintended racial segregation happening in lecture halls and social circles may have a long-term negative impact on interactions with our colleagues and patients from different backgrounds, and we should use the resources and structures in place to address this earlier in the medical training.

Evidence shows the negative impact of implicit bias particularly on black and Latino patients. Both groups are underrepresented among physicians, while Asian and white doctors are well represented. Studies show that the most effective way to counter one’s biases is to develop positive relationships with members of the “out-group” in question.

The medical field’s attempts to mitigate the effects of implicit bias have so far intuitively focused more on the clinical years. This is manifested via education for trainees and attending physicians, including diversity training, and more informal ways such as book clubs. We pay less attention to the preclinical years. For preclinical students like myself, structures to contribute to addressing implicit bias already exist. Targeting ways in which students interact with peers is an option. Several national organizations are calling for the emphasis of teamwork in medical school, and those changes are implemented in our introduction to the clinical world, including the more recent emphasis put on interprofessionalism. The intentionality driving interprofessional experiences where medical students work with allied-health peers can be mirrored in ensuring that group experiences for preclinical students reflect the diversity of their environment. Staff mention that gender balance is important when creating groups for longitudinal experiences. What if, paired with the emphasis on the importance of teamwork and diversity, groups were intentionally made to be diverse beyond gender?

Further de-randomizing groups could afford more predictable opportunities for students to interact with peers from different backgrounds in settings that may contribute to creating great relationships. As many medical schools thoughtfully shift towards flipped classroom and team-based learning models, students have more opportunities for interactions across professions, levels of training and social groups. Some may argue in favor of group homogeneity. This is, however, a mechanism already in place through extracurricular social networks and affinity groups, often institutionally supported.

Changes to the landscape could have a positive effect on what students value. Given that the portraits adorning the walls of our schools recognize mostly white men, we should restructure the ways in which space is allocated for portraiture. For example, allocating space recognizing students, recent alumni and faculty for their academic prowess could contribute to a landscape more reflective of its dwellers. While social scientists refer to the concept of landscape fairness as aiming to remove forms of discrimination in a built-in environment, I aim to emphasize the importance of recency in the landscape, related to not only fair representation but also temporal proximity for students with respect to those who are celebrated through portraiture. Such recency is likely more inspiring because of commonalities afforded by aforementioned proximity. For example, as a freshman at Howard University, I was inspired by portraits of seniors and recent alumni who were Fulbright fellows and Rhodes scholars because I saw myself in them.

As we aim to mitigate the impact of implicit bias on clinical care, we must remember that bias is not isolated to clinical settings and has effects on interpersonal relationships within the profession. We must also note that negative implicit attitudes towards racial and ethnic minorities in our society are a part of the larger issue that is structural racism. Addressing implicit bias must be done well before the clinical years through a longitudinal approach, but it must also be part of larger synergistic efforts aiming to combat structural racism and the ways in which it affects health.

The author would like to thank Douglas Shenson, MD and Benjamin Oldfield, MD for their guidance in the conceptualization of this article.

Max Jordan Nguemeni Tiako is a medical student.Author's addendum: A young Nigerian student who moved to the United States had this to say, " I did not know I was black until I moved to the United States."

Tuesday, January 30, 2018

Introduction

Average out-of-pocket cost for Medicare beneficiaries are expected to keep rising over the next decade when it will reach half of a senior's income.

The Kaiser Family Foundation estimated that out-of-pocket costs will increase from 41% of average per capita Social Security income in 2013 to 50% by 2030.

In its analysis of 2013 numbers, KFF said women paid 44% of their per capita income on out-of-pocket costs, which was more than men, who paid 38% on out-of-pocket costs. That’s expected to increase to 52% and 47% respectively by 2030.

Medicare helps pay for the health care needs of 59 million people ages 65 and over and younger people living with permanent disabilities. Yet, people with Medicare can face significant health-related out-of-pocket costs, including premiums, deductibles, cost sharing for Medicare-covered services, and costs for services Medicare does not cover, such as long-term services and supports and dental services. With half of all Medicare beneficiaries living on annual per capita income ofless than $26,200, out-of-pocket health care costs can pose a challenge, particularly for beneficiaries with modest incomes and those with significant medical needs.

As one way of measuring health care affordability for people with Medicare, each year the Medicare Trustees estimate Medicare Part B and Part D premiums and cost sharing as a share of average Social Security benefits. This estimate, however, does not include other health-related costs, such as out-of-pocket spending on hospital and skilled nursing facility stays, supplemental insurance premiums, and costs for services not covered by Medicare. The estimate also does not include income from sources other than Social Security.

In this analysis, we assess the current and projected out-of-pocket health care spending burden among Medicare beneficiaries using a broad definition of health care expenses, and in relation to both per capita Social Security and total income. Our results suggest that rising health care costs pose significant affordability challenges for many people on Medicare today, particularly those with relatively low incomes who derive most of their income from Social Security, and that this burden can be expected to grow in the future. This analysis sets the context for understanding the implications of potential changes to Medicare, Medicaid, or Social Security that could shift more health care costs onto beneficiaries or reduce their future retirement income.

Monday, January 29, 2018

Dr. Farago is a family doctor, articulate and funny ! He takes a subject which is causing major problems in health care administration. Patients must know what has happened to physicians in the past twenty years.

He has adopted direct patient care to avoid the unsolvable Kobyashi Maru. He elaborates on the shell game of hospital administrators, creating chaos, confusion and distraction. Learn how he escaped from the jewel of the north and the pearl of the east. Incidentally he worked at a Federally Qualified Medical Center.

For my fellow colleagues, you are welcome to watch this video as well, and weep. I know there is not one of you who does not agree with Doug Farago M.D.

It ia not a good time for the United States, nor is it for medicine. However we will change it. After all we cure and conquer diseases now that were unmanageable in the past. No one can identify one particular even that changed everything. Those of us who are as old as I am remember certain events precipitated by laws which destroyed the freedom of patients while promising less expensive and more availability of health care. None of that proved to be true. Yet physicians protested, but did not revolt. The shell game was in progress.

Saturday, January 13, 2018

Pathetic, shameful and a disgrace ! One of the key measures of a society is how children are treated and more important protected. A key measure is infant mortality rates, vaccination rates and other metrics. It is well known that the United States is not in the top ranking of chldren's survival rates.There are numerous governmental agencies that compile this information, to include:

Sunday, January 7, 2018

If true and verified and credible it adds much to the alcoholism preferred pattern of practice I am Dr George Lundberg, and this is At Large at Medscape. September is "be kind to addicts" month (officially National Recovery Month). How can we help?

Of every 100 Americans who drink (140 million), about 12 (16 million) are considered in need of treatment for an alcohol use disorder, and eight will become chemically dependent on alcohol.[1] Of that eight, one will become addicted very early, even after the first drunken episode. The problem is, we do not yet have a way to predict who that one person will be.

Prevention is always the best answer to addiction. Do not drink. If you do drink, do not ignore the warning signs of becoming a problem drinker.

Let me ask you: How is your blood acetaldehyde today; or, more relevant, how was it late last night? You don't know? Why am I not surprised? Most people don't even think about acetaldehyde.

Ethyl alcohol is metabolized to acetaldehyde by alcohol dehydrogenase in the liver. Acetaldehyde is metabolized to acetate by aldehyde dehydrogenase and then to carbon dioxide and water. Depending on the alcohol dose, some of the acetaldehyde may escape hepatic metabolism and enter the general blood circulation.

Acetaldehyde is a close cousin to my old pathology lab friend formaldehyde. We use it to pickle surgical and autopsy tissues for preservation. Both are known carcinogens. Our body's defense mechanism against excess acetaldehyde is the amino acid l-cysteine and glutathione. These molecules, similarly to thiamine, contain a sulfhydryl group that is chemically active against aldehydes.

Unless you are one of those people (typically East Asian) who are genetically deficient in aldehyde dehydrogenase or are taking disulfiram, you can metabolize roughly one stiff drink per hour. If you drink more than that, depending on body weight, gastric contents, and the efficiency of your metabolic alcohol breakdown, acetaldehyde will build up because aldehyde dehydrogenase capability can be overwhelmed.

If you quit drinking at 11:00 PM, then around about 1:00 AM, your acetaldehyde level may be elevated and you may feel symptoms of acetaldehyde toxicity, including skin flushing, tachycardia, palpitations, anxiety, nausea, thirst, chest pain, and vertigo. Of course, you are trying to "sleep it off," so you may not feel toxic until the next morning when that dreaded hangover appears.

Metabolizing Alcohol

My friends in the nutritional supplement community tell me that you can enhance the metabolism of blood alcohol to acetate, carbon dioxide, and water and minimize the acetaldehyde molecular logjam by taking oral supplements. L-cysteine, vitamin C, and vitamin B1 are purported to help. At supplement doses, they are cheap and harmless at worst. At best: Goodbye, acetaldehyde toxicity; hello, restful sleep. About 200 mg of L-cysteine per ounce of alcohol consumed is sufficient to block a major portion of the toxic effect of acetaldehyde. But because alcohol is absorbed and metabolized rapidly, it may be necessary to take L-cysteine before and concurrently with consumption to maintain protection. Also, an excess of vitamin C (perhaps 600 mg) can help keep the L-cysteine in its reduced state and "on the job" against acetaldehyde. Experts recommend these doses (with or without extra B1): one round before drinking, one with each additional drink, and one when finished.

Some say that this regimen works very well. Do not ask me for a list of published randomized, double-blind clinical trials. Not yet, at least. Research funding into "harm reduction" from addicting substances has not enjoyed favored status in research priorities.

Unfortunately, this concoction may have little effect on next-day hangovers, the causes of which are complex and resistant to prevention—except, obviously, by not drinking too much, which is, of course, the best answer to alcohol anyway.

Disclaimer

The opinions in this blog or other forms of social media are solely that of Gary M. Levin M.D. Dr. Levin has no financial interests in any medical devices which are discussed or which appear in the blog. Commentary taken from other sources are either quoted or referenced with attribution. Dr Levin does not endorse, nor give financial support to any political organizations.